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GASTROENTEROLOGY 2012;xx:xxx
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Continuing Medical Education Answers: July 2012Exam 1: Efficacy of 5-Day Levofloxacin-Based Concomitant Therapy in
Eradication of Helicobacter pylori Infection 6789
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Question 1:
Answer: d
Rationale:
Clarithromycin resistance is steadily increasing in different areas of the world.1 Resistance to amoxicillinnd tetracycline is rare.2 Although clarithromycin resistance in vitro predicts resistance in vivo, resistance to
metronidazole and its analogs may be overcome in vivo by increasing the dose and/or the duration oftreatment. Because of this, in areas where resistance to clarithromycin is �15%, it is recommended not touse regimens containing this antimicrobial as first-line therapy.3
References1. Graham DY, Shiotani A. New concepts of resistance in the treatment of Helicobacter pylori infection. Nat Clin Pract Gastroenterol Hepatol
2008;5:321–331.. Romano M, Iovene MR, Russo MI, et al. Failure of first line eradication treatment significantly increases prevalence of antimicrobial resis-
tant Helicobacter pylori clinical isolates. J Clin Pathol 2008;61:1112–1115.. Malfertheiner P, Megraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection-The Maastricht III
Consensus Report. Gut 20017;56:772–781.
Question 2:
Answer: d
Rationale:
It is known that bacteria are able to develop efflux channels for clarithromycin, which rapidly transfer thedrug out of the bacterial cell, preventing the binding of the antibiotic to the ribosome. It has been speculatedthat the disruption of the bacterial cell wall by amoxicillin prevents the development of these effluxchannels, thereby improving the efficacy of clarithromycin in the second period of treatment. However, thegreater efficacy of sequential treatment has also been attributed to the larger number of antimicrobials towhich the bacterium is exposed. The latter hypothesis is also corroborated by the fact that concomitantadministration of the 3 antimicrobials achieves similar eradication rates than sequential administration ofthe same drugs.1,2
References1. Gisbert JP, Calvet X, O’Connor A, et al. Sequential therapy for Helicobacter pylori eradication: a critical review. J Clin Gastroenterol 2010;
44:313–325.. Gisbert JP, Calvet X. Review article: non-bismuth, quadruple (concomitant) therapy for eradication of Helicobacter pylori. Aliment Pharma-
col Ther 2011;34:604–617.
Question 3:
Answer: b
Rationale:
A 95% efficient empiric eradication therapy is still far from being available. The use of in vitro suscepti-bility testing might help to improve the efficacy of therapy,1 but it depends on an invasive procedureesophagogastroduodenoscopy). In addition, culture is not always successful. It is therefore important toontinuously monitor the prevalence of antimicrobial resistance of H pylori clinical isolates in order to
hoose the combination of drugs that has the highest chance of being effective locally. 57
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e2 CME ACTIVITY GASTROENTEROLOGY Vol. xx, No. x
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100101102103104105106107108109110111112113114
Reference1. Romano M, Marmo R, Cuomo A, et al. Pretreatment antimicrobial susceptibility testing is cost-saving in the eradication of Helicobacter
pylori. Clin Gastroenterol Hepatol 2003;1:273–278.
Question 4:
Answer: d
Rationale:
Fluoroquinolones have been used in several clinical trials and have shown greater efficacy than clarithro-mycin-containing eradication regimens.1,2 In particular, in an area with high prevalence of clarithromycin
nd dual resistance, the efficacy of a levofloxacin-containing sequential therapy was as high as 95%.3
However, resistance to this antimicrobial is increasing in different areas of the world4; therefore, cautionust be used in recommending levofloxacin-containing regimens as first-choice therapy without knowing
he prevalence of H pylori strains resistant to levofloxacin in a given area.
References1. Romano M, Cuomo A, Gravina AG, et al. Empirical levofloxacincontaining versus clarithromycin-containing sequential therapy for Helico-
bacter pylori eradication: a randomised trial.Gut 2010;59:1465–1470.2. Molina-Infante J, Perez-Gallardo B, Fernandez-Bermejo M, et al. Clinical trial: clarithromycin vs levofloxacin in first-line triple and sequential
regimens for Helicobacter pylori eradication. Aliment Pharmacol Ther 2010;31:1077–1084.3. Gisbert JP, Calvet X, O’Connor A, et al. Sequential therapy for Helicobacter pylori eradication: a critical review. J Clin Gastroenterol 2010;
44:313–325.4. Glocker E, Stueger HP, Kist M. Quinolone resistance in Helicobacter pylori isolates in Germany. Antimicrob Agents Chemother 2007;51:
346–349.
Exam 2: Efficacy of Neoadjuvant Chemoradiation, Followed by LiverTransplantation, for Perihilar Cholangiocarcinoma at 12 US Centers
Question 1:
Answer: d
Rationale:
In the combined neoadjuvant chemoradiotherapy followed by transplantation protocol, 65% disease-freesurvival at 5 years was demonstrated. Initial reports of transplantation alone, in the absence of neoadjuvanttherapy, for patients with perihilar cholangiocarcinoma showed 3-year survival of only 25%, which led to theabandonment of this treatment strategy.
Question 2:
Answer: b
Rationale:
This statement is false. Intrahepatic cholangiocarcinoma is an exclusion criterion for this protocol, whichis designed to treat those with unresectable perihilar disease, which is the most common form ofcholangiocarcinoma.
Question 3:
Answer: e
Rationale: 115
Month 2012 CME ACTIVITY e3
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116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172
The most common side effect was cholangitis, which is universal. Fatigue was common (41%), and ulcerswere seen in 34%. Portal vein stricture is a common complication posttransplant and required interventionin 23% of patients.
Question 4:
Answer: a
Rationale:
This statement is true. The standard Model for End-Stage Liver Disease score exception that wasdesignated for patients with perihilar cholangiocarcinoma was set to mirror that of hepatocellular carci-noma, because the actual waitlist dropout risk was unknown; until the current publication, there were nodata on the waitlist dropout rate for patients with perihilar cholangiocarcinoma undergoing the combinedtreatment protocol. We were able to demonstrate that the dropout rate per 3 months averaged 11.5%, whichapproximates the expected 10%, and hence justifies its use.
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